Provider Demographics
NPI:1972688265
Name:HERDMAN, JOHN W (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:HERDMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4706 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-1276
Mailing Address - Country:US
Mailing Address - Phone:402-489-9792
Mailing Address - Fax:402-489-9793
Practice Address - Street 1:1640 L ST STE C
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68508-2581
Practice Address - Country:US
Practice Address - Phone:402-489-9792
Practice Address - Fax:402-489-9793
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE451103TA0400X
NE424103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47081184000Medicaid
NE08363OtherBLUE CROSS BLUE SHIELD
NE099166Medicare ID - Type Unspecified